Kimberly Salkey, M.D. Department of Dermatology Eastern Virginia Medical School

1. Clinical Pearls: Dermatologic Findings of Nails and Hair American College of Physicians2013 Virginia Chapter Annual Meetingand Clinical Update Kimberly Salkey, M.D. Department of Dermatology Eastern Virginia Medical School

2. I have no conflicts of interest to declare

3. Patient 1 Chief Complaint: Hair loss

4. Patient 1 • History • Excessive shedding • Smaller ponytail • Just married 3 months ago • Examination • Diffuse ↓ in hair density • Scalp, brows, lashes WNL • Hair pull positive

5. Telogen Effluvium • Excessive and early entry of hairs into the telogen phase • Triggered by emotionally or physiologically stressful events • Shedding begins 2-4 months after trigger • > 25% of hairs in telogen phase • Hair loss can approach 400-500/day

6. Human Hair Cycle

8. Up to 100 scalp hairs shed/day 100,000 scalp hairs Few months 2-7 years 90% 10%

9. Telogen Effluvium

10. Childbirth Severe infection Severe chronic illness Severe psychological stress Major surgery Hypo or hyperthyroidism Crash diets inadequate protein Drugs Causes of Telogen Effluvium

11. Management of Telogen Effluvium • Laboratory evaluation • Directed by history • Thyroid studies, CBC, Iron studies • Check medications • βblockers, NSAIDS, anti-coagulants, HRT • Reassurance • Reassurance • Minoxidil

12. Clinical Pearl • Acute onset, diffuse hair shedding occurring a few months after a major stressor • Identify cause • Offer reassurance re: self limited course Telogen Effluvium

13. Patient 2 Chief Complaint: Toe nail discoloration

14. Patient 2 • History • Discoloration for years • Itchy feet • Healthy • No skin disease • Examination • Similar findings on both feet

15. Onychomycosis • AKA tinea unguium • 3 types • Distal/lateral subungual • Most common • White superficial • Direct invasion of superficial nail plate • Proximal subungual • Immunocompromised hosts

16. Onychomycosis

17. Onychomycosis

18. Onychomycosis

19. Onychomycosis • White spotting due to superficial dermatophyte infection or trauma

20. Onychomycosis Evaluation and Treatment • Culture to confirm diagnosis • Terbinafine 250mg PO qd • Fingernails- 6 weeks • Toenails- 12 weeks • Itraconazole • 200 mg PO qd x 12 weeks OR • 200 mg BID x 1 week/month for 3-4 consecutive months • Griseofulvin • Fluconazole • Ciclopirox nail lacquer

21. Clinical Pearl:Onychomycosis • Confirm diagnosis • Patient education • Frequent recurrence • Potential side effects of treatment

22. Patient 3 Chief Complaint: Hair loss

23. Patient 3 • History • Abrupt onset • Gradually enlarging • Otherwise well, cousin with vitiligo • Examination • Sharply demarcated round patch of alopecia • Hair pull positive at periphery • “shaggy” pits in the fingernails

24. Alopecia Areata • Autoimmune disorder • Acute onset • Well circumscribed, round or oval patches • Males=females

25. N Engl J Med 2012;366:1515-25.

26. N Engl J Med 2012;366:1515-25.

27. Alopecia Areata

29. Alopecia Areata • Diagnosis • Usually based on clinical findings • Skin biopsy: lymphocytic infiltrate surrounds early anagen hair bulbs “swarm of bees” • Treatment • Topical, intralesional corticosteroids • Oral steroids • CAUTION: may experience hair loss after discontinuation • Immunotherapy • Phototherapy • Cyclosporine and Methotrexate will

30. Alopecia Areata • Variable course • Relapses occur • Poor prognosis • Duration more than one year • Extensive hair loss • Onset at age <5 years • Family history of alopecia areata

31. Clinical Pearl:Alopecia Areata • Acute onset • Well defined • Oval or round patches of alopecia Gold Standard:Intralesional kenalog

32. Patient 4 N ENGL J MED 2011; 364:E38 Chief Complaint: Toe nail discoloration

33. Patient 4 • History • 37yo man • 4 year history of gradual darkening and widening of pigmented band • Examination • Brown/Black extension to proximal nail fold- Hutchinson’s sign N ENGL J MED 2011; 364:E38

34. Palm, sole or nail bed Median age 65 50-70% of melanomas in African Americans and Asians Acral Lentiginous Melanoma

36. Minocycline Anti-malarials Gold

37. Nail matrix nevus

38. Nail matrix nevus

39. A patient with HIV taking zidovudine

40. Subungual hematoma

41. Pseudomonas nail infection

42. Clinical Pearl:Melanonychia • Check for Hutchinson’s sign- extension of pigment to proximal nail fold • If negative, consider • Normal variant • Traumatic • Drug induced

43. Patient 5 Chief Complaint: Hair loss

44. Patient 5 • History • Gradually thinning on top since age 20’s • Dad’s hair also thin • No known medical problems • Examination • ↓↓ density of frontal scalp with recession of frontal hair line • Many miniaturized hairs

45. Androgenetic Alopecia-MEN • 50% by age 50 years • Androgen dependent progressive decline in anagen duration • Genetic predisposition • Hair follicles miniaturize • Hair loss occurs in the fronto-temporal regions and the vertex Uptake, metabolism, and conversion of testosterone to dihydrotestosterone by 5-alpha-reductase is increased in balding hair follicles.

46. Androgenetic Alopecia

47. Female Pattern Hair Loss Androgenetic Alopecia • WOMEN • With or without androgen excess • Early or late onset • Hairs of variable diameter • Top of scalp most significantly involved

48. Female Pattern Hair Loss

49. Androgenetic Alopecia • Progressive shortening of successive anagen cycles • Miniaturization

50. Androgenetic Alopecia Ludwig Hamilton-Norwood